The relationship between physician burnout and depression, anxiety, suicidality and substance abuse: A mixed methods systematic review.

Introduction: The World Health Organization defines burnout as a problem associated with employment, a category distinct from psychological disorders such as depression, anxiety, suicidality and disorders of substance abuse. Evaluating the association between burnout as an occupational exposure and psychological morbidity may indicate that burnout can act as an occupational risk factor for mental ill-health. The systematic review explores this relationship in physicians due to the increased risk in this population and the implications for healthcare delivery. Methods: A mixed methods systematic review of the literature was conducted across Medline, Cinahl Plus, PsycInfo, Web of Science and The Cochrane Library. Databases were systematically searched using keywords relating to physician burnout and depression, anxiety, suicidality and substance abuse. Identified articles were screened for eligibility by two independent researchers. Data extraction was performed and studies assessed for risk of bias. Quantitative and qualitative results were integrated using a convergent segregated approach and results portrayed as a narrative synthesis. Results: Sixty-one articles were included in the review. There was notable heterogeneity in the measurement and criteria used to define burnout limiting the assimilation of results. Despite this, all studies that measured the association between depression and burnout reported a significant association. Studies that reported association between burnout and anxiety were similarly uniformly consistent. Most studies that reported the association between burnout and suicidality indicated that a significant association exists however difficulty in measurement of suicidality may have influenced variability of results. The reported association between substance abuse and burnout was more variable, suggesting that any association is likely to be weak or influenced by other variables. Qualitative studies described the manifestations of chronic workplace stress as well as perceived links with psychological morbidity. These included lack of time for work-life balance, the contribution of professional relationships and a culture of invulnerability that exists among physicians. Conclusion: The systematic review cannot conclude causality but suggests that physician burnout is associated with depression, anxiety and suicidality. Qualitative data provides insight into the nature of this association. The review indicates the need for longitudinal research and provides considerations for intervention strategies to prevent the development and progression of burnout. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172938, identifier: CRD42020172938.

The Alberta oil sands eroded bitumen/sediment transitional journey: Influence on sediment transport dynamics, PAH signatures and toxicological effect.

This paper investigated the sediment/contaminant continuum of bitumen containing sediment, from eroded exposed natural bitumen outcrops to river depositional zone, in order to improve our understanding of the transitional sediment, chemistry and toxicological influence on aquatic health. To achieve this aim, we linked a rainfall simulator with an annular flume to allow for connectivity between terrestrial erosion to stream flow. Bulk sediments were collected from the minable McMurray Formation (MF) on the Ells (EL) and Steepbank (STB) Rivers and from the Clearwater Formation (CF) on the STB. All plots generated similar washoff rates (~25 L hr-1) and fine eroded sediment (d50 = 5 µm) regardless of strata. The CF generated the highest total eroded sediment (TES) followed by EL-MF and STB-MF. The STB-MF generated up to three orders of magnitude lower TES than the STB-CF. The EL generated the highest PAH concentrations, however, when normalizing by TES mass delivered to the flume, STB-MF PAH was one to two orders of magnitude higher per unit mass than EL-MF. The TES concentrations were inversely proportional to the degree of bitumen within the sediment (STB-MF > EL-MF > STB-CF). Once the TES was suspended in the flume, there was a change in the dominant PAH for most classes [e.g., Dibenzothiophenes C4 (parent material) to a C3 (TES)]. Further, no flocculation and the buoyant properties of the TES suggested that the sediment and associated PAHs may travel long distances. The EL-MF proved to be the most toxic to fathead minnow embryo survival due principally to the high PAH concentrations and sediment loads. The CF exhibited no toxicological effect. This work has shown the importance of assessing sediment/contaminant characteristics over the continuum (terrestrial erosion/washoff to river deposition) in order to support basin wide management strategies for the protection of aquatic health.

Adapting health interventions for local fit when scaling-up: a realist review protocol.

INTRODUCTION: Scaling-up is essential to ensure universal access of effective health interventions. Scaling-up is a complex process, which occurs across diverse systems and contexts with no one-size-fits-all approach. To date, little attention has been paid to the process of scaling-up in how to make adaptations for local fit. The aim of this research is to develop theory on what actions can be used to make adaptations to health interventions for local fit when scaling-up across diverse contexts that will have practical application for implementers involved in scaling-up. METHODS AND ANALYSIS: Given the complexity of this subject, a realist review methodology was selected. Specifically, realist review emphasises an iterative, non-linear process, whereby the review is refined as it progresses. The identification of how the context may activate mechanisms to achieve outcomes is used to generate theories on what works for whom in what circumstances. This protocol will describe the first completed stage of development of an initial programme theory framework, which identified potential actions, contexts, mechanisms and outcomes that could be used to make adaptations when scaling-up. It will then outline the methods for future stages of the review which will focus on identifying case examples of scale-up and adaptation in practice. This realist review consists of six stages: (i) clarifying scope and development of a theoretical framework, (ii) developing a search strategy, (iii) selection and appraisal, (iv) data extraction, (v) data synthesis and analysis and (vi) further theory refinement with stakeholders. ETHICS AND DISSEMINATION: This review will develop theory on how adaptations can be made when scaling-up. Findings will be disseminated in a peer-reviewed journal and through stakeholder engagement as part of the research process. Ethical approval has been received through Health Policy and Management/Centre for Global Health Research Ethics Committee of Trinity College Dublin.

Temporal and spatial trends in riverine suspended sediment and associated polycyclic aromatic compounds (PAC) within the Athabasca oil sands region.

Bitumen-bearing suspended sediment (SS) eroded from the McMurray Formation (MF) are fine grained (silts and clays) and coated with natural hydrophobic oils. This results in poor settling and long range transport of associated contaminants. There was a longitudinal increase in polycyclic aromatic compound (PAC) concentrations for rivers that erode the MF from upstream to downstream regardless of time-of-year, while loads were substantially increased during high flow periods when the erosive forces are the greatest and the overland flow contribution is high. Within the MF, variation in PAC contributions is seen by the Ells River having higher loads than the Steepbank River. Using the Ells and Steepbank as examples, double plot PACs ratios suggest that the PAC concentrations and signatures vary spatially within the MF but that the weathering processes may be the same. Plots of the various homologs of PACs generally illustrated a normal distribution which suggests petrogenic origins. However, several PAC ratios suggested that both the parent material and the SS are pyrogenic in nature. While it is likely that some level of atmospheric deposition (anthropogenic or from forest fire) is incorporated into the SS of the rivers, it is likely to be limited relative to the proportion of naturally eroded MF sediments. Additional analysis will be needed to distinguish the relative risk of both anthropogenic (e.g., industrial operations) and natural sources (bitumen deposits, forest fire) of PACs to the SS and to long-range depositional environments, as they may have potential aquatic ecological effects.

Assistive technology policy: a position paper from the first global research, innovation, and education on assistive technology (GREAT) summit.

Increased awareness, interest and use of assistive technology (AT) presents substantial opportunities for many citizens to become, or continue being, meaningful participants in society. However, there is a significant shortfall between the need for and provision of AT, and this is patterned by a range of social, demographic and structural factors. To seize the opportunity that assistive technology offers, regional, national and sub-national assistive technology policies are urgently required. This paper was developed for and through discussion at the Global Research, Innovation and Education on Assistive Technology (GREAT) Summit; organized under the auspices of the World Health Organization's Global Collaboration on Assistive Technology (GATE) program. It outlines some of the key principles that AT polices should address and recognizes that AT policy should be tailored to the realities of the contexts and resources available. AT policy should be developed as a part of the evolution of related policy across a number of different sectors and should have clear and direct links to AT as mediators and moderators for achieving the Sustainable Development Goals. The consultation process, development and implementation of policy should be fully inclusive of AT users, and their representative organizations, be across the lifespan, and imbued with a strong systems-thinking ethos. Six barriers are identified which funnel and diminish access to AT and are addressed systematically within this paper. We illustrate an example of good practice through a case study of AT services in Norway, and we note the challenges experienced in less well-resourced settings. A number of economic factors relating to AT and economic arguments for promoting AT use are also discussed. To address policy-development the importance of active citizenship and advocacy, the need to find mechanisms to scale up good community practices to a higher level, and the importance of political engagement for the policy process, are highlighted. Policy should be evidence-informed and allowed for evidence-making; however, it is important to account for other factors within the given context in order for policy to be practical, authentic and actionable. Implications for Rehabilitation The development of policy in the area of asssitive technology is important to provide an overarching vision and outline resourcing priorities. This paper identifies some of the key themes that should be addressed when developing or revising assistive technology policy. Each country should establish a National Assistive Technology policy and develop a theory of change for its implementation.

Opportunities for human resources for health and rehabilitation: a response to Jesus et al.

We welcome Jesus et al.'s paper, which makes an important contribution to the under-researched area of the physical rehabilitation workforce. The authors present recommendations to "advance a policy and research agenda for ensuring that an adequate rehabilitation workforce can meet the current and future rehabilitation health needs" (p. 1). We argue that their perspective could however be strengthened by adopting a stronger global perspective, including consideration of the needs of low-resource settings. In particular, we highlight the integral role of more effective sector and inter-sectoral governance, the opportunity to support the development of community-based rehabilitation (CBR), the lessons that can be learnt from human resources for health (HRH) research and practice more generally, and the recent developments in the global provision of assistive technologies. Each of these issues has important implications and contributions to make to advance the policy and research agenda for the global rehabilitation workforce.

An Exploratory Thematic Analysis of the Breastfeeding Experience of Students at a Canadian University.

BACKGROUND: The demographic of today's university student includes breastfeeding mothers. Few studies have examined the breastfeeding experience that women face upon their return to school. Research aim: The purpose of this research was to explore the breastfeeding experience of students on a university campus. METHODS: This qualitative study used semistructured interviews. Responses were audiotaped, transcribed, and coded according to common themes using MAXQDA software. RESULTS: A total of eight women were interviewed for the study. All women reported "feelings of isolation" and expressed concern over "what will others think." In addition, "nowhere to breastfeed" and "challenges of pumping" emerged as common barriers to breastfeeding. Regrettably, "forced decisions" emerged as a major theme, with four out of eight women reporting having to supplement with formula because they returned to school. CONCLUSION: Student breastfeeding mothers are faced with emotional and physical challenges upon their return to school. Lack of space to breastfeed or pump as well as lack of support on campus are the main reasons that students stop breastfeeding prematurely. A day care facility on campus that accepts young infants, a Baby-Friendly space, and enhanced education are required to support student mothers in their choice to breastfeed.

Risk based monitoring (RBM) tools for clinical trials: A systematic review.

INTRODUCTION: In November 2016, the Integrated Addendum to ICH-GCP E6 (R2) will advise trial sponsors to develop a risk-based approach to clinical trial monitoring. This new process is commonly known as risk based monitoring (RBM). To date, a variety of tools have been developed to guide RBM. However, a gold standard approach does not exist. This review aims to identify and examine RBM tools. METHODS: Review of published and grey literature using a detailed search-strategy and cross-checking of reference lists. This review included academic and commercial instruments that met the Organisation for Economic Co-operation and Development (OECD) classification of RBM tools. RESULTS: Ninety-one potential RBM tools were identified and 24 were eligible for inclusion. These tools were published between 2000 and 2015. Eight tools were paper based or electronic questionnaires and 16 operated as Service as a System (SaaS). Risk associated with the investigational medicinal product (IMP), phase of the clinical trial and study population were examined by all tools and suitable mitigation guidance through on-site and centralised monitoring was provided. CONCLUSION: RBM tools for clinical trials are relatively new, their features and use varies widely and they continue to evolve. This makes it difficult to identify the "best" RBM technique or tool. For example, equivalence testing is required to determine if RBM strategies directed by paper based and SaaS based RBM tools are comparable. Such research could be embedded within multi-centre clinical trials and conducted as a SWAT (Study within a Trial).

Age-related differences in memory expression during infancy: using eye-tracking to measure relational memory in 6- and 12-month-olds.

Relational memory, or the ability to bind components of an event into a network of linked representations, is a primary function of the hippocampus. Here we extend eye-tracking research showing that infants are capable of forming memories for the relation between arbitrarily paired scenes and faces, by looking at age-related changes in relational memory over the first year of life. Six- and 12-month-old infants were familiarized with pairs of faces and scenes before being tested with arrays of three familiar faces that were presented on a familiar scene. Preferential looking at the face that matches the scene is typically taken as evidence of relational memory. The results showed that while 6-month-old showed very early preferential looking when face/scene pairs were tested immediately, 12-month-old did not exhibit evidence of relational memory either immediately or after a short delay. Theoretical implications for the functional development of the hippocampus and practical implications for the use of eye tracking to measure memory during early life are discussed.